COLLEGE OF NURSING SILLIMAN UNIVERSITY

DUMAGUETE CITY

RESOURCE UNIT ON THE CARE OF DEPRESSED, WITHDRAWN AND SUICIDAL PATIENTS

Submitted by:

Sarah Charlina Abanto

Micca Borja

NCM 105 – A1

(Psychiatric-Mental Health Nursing Rotation)

Submitted to:

Asst. Prof. Lorelei M. Bacay

COLLEGE OF NURSING

SILLIMAN UNIVERSITY

Vision: As a leading Christian Institution in Asia, Silliman University is committed to total human development for societal and environmental well-

being.

Mission: In this regard, the University:

o Provides opportunities for all members of the academic community to seek justice, truth, and love.

o Pursues excellence in every dimension of inquiry, learning and teaching.

o Instills in all members of the university community-including all its integral units-an enlightened social consciousness, a profound

sense of involvement, and a genuine compassion for every person.

o Enhances national development and unity by making its life and programs relevant to the total environment.

COLLEGE OF NURSING SILLIMAN UNIVERSITY

DUMAGUETE CITY

RESOURCE UNIT ON THE CARE OF DEPRESSED, WITHDRAWN AND SUICIDAL PATIENTS

PLACEMENT: Level IV – First Semester

TIME ALLOTMENT: 2 hours

TOPIC DESCRIPTION: This topic deals with the Care OF depressed, withdrawn & suicidal patients. It also includes the risk factors, signs & symptoms, the types

& the nursing responsibilities.

CENTRAL OBJECTIVE: At the end of 2 hours, the learner shall have gained more knowledge, developed beginning skills and manifested positive attitudes and

values toward the care of depressed, withdrawn & suicidal patients.

Specific Objectives Content T/A T/L Activities Evaluation

I. Prayer

Almighty Father, we worship You & we give You thanks for all the graces &

blessings that you have given to us. Thank you for giving us another opportunity to

live & be with our family, friends & loved ones. We humbly ask for Your

forgiveness for our wrong doings. Today Lord, we ask for Your guidance as we

present our assigned topics. May You continue to bless us each day & send forth

Your Holy Spirit to be with us always. May You also continue to protect us all

from any form of harm & danger. We just lift to You Lord, all our personal

intentions. Amen.

II. Introduction

Everyone experiences the highs & lows of life. Mood disorders are characterized

by exaggerations of that variability in mood. Being too high or too low or

2 min.

3 min.

Oral Evaluation

through Question

and Answer

Given the resources,

the learner shall:

1. Correctly define the

related terms in their

own words.

experiencing both extremes causes intrapersonal & interpersonal anguish.

However, because experiencing life’s ups & downs is normal, & indeed it would be

unnatural not to do so, it is not always clear where the line between normal &

abnormal, or between healthy & unhealthy, should be drawn. The “depressed”

person & others in that person’s life recognize the “normalness” of the response &

the person eventually is able to “get on with life.” In contrast, if the sadness or guilt

goes on too long, an imaginary line is crossed at some point & a clinically

significant mood disorder exists. Mood disorders are the most common psychiatric

diagnoses associated with suicide; Depression is one of the most important risk

factors.

III. Definition of Related Terms

Depression – mood disturbance characterized by feelings of sadness,

despair, apathy & discouragement caused by loss in the person’s life or by

neurobiological imbalance

Depressive Personality – a lifestyle or character disorder in which the

person is chronically “down”, is pessimistic, is a complainer, is unhappy

with job, family, life position

Suicide – self-inflicted death; the intentional act of killing oneself

Suicide Gesture – suicide attempt directed toward the goal of receiving

attention rather than actual destruction of the self

Suicide Threat – usually occurs before overt suicidal activity takes place

Suicide Attempt – include any self-directed actions taken by the person that

will lead to death if not interrupted

IV. Depression

Everyone feels sad or guilty from time to time in response to the events of

life. If the sadness or guilt persists for too long, a diagnosable cognition

exists. Examples include, loss of loved one through death, a sense of shame

or guilt for an unacceptable behavior or a feeling of failure (failing the

5 min.

10 min.

Group Discussion

Socialized

Discussion

2. Enumerate 5 signs

& symptoms,

(respectively) of

Depression

3. Discuss the different

signs (objective or

subjective) of

depression briefly.

board exam, divorce, etc.)

A. Symptoms of Depression:

Common Symptoms Other Symptoms

Apathy (inability to be motivated &

interested)

Sadness

Sleep Disturbances (Insomnia or

Hypersomnia)

Hopelessness

Helplessness

Worthlessness

Guilt

Anger (Covert or overt)

Fatigue

Thoughts of Death

Decreased Libido

Ruminations of inadequacy

Psychomotor agitation

Private verbal beratings of self

Spontaneous crying without apparent

cause

Dependency

Passiveness

B. Signs of Depression

Objective:

Aggressiveness (these patients become irritable when disturbed; they may

seek to be alone not wanting anyone to talk to or distract them from their

obsessions in the inner world)

20 min.

Socialized

Discussion

Irritability

Alterations of activity - Patients may exhibit psychomotor agitation. They

may be unable to sit still & may pace & engage in hand-wringing & pulling

or rubbing their hair, skin or other objects. Tying & retying shoes, &

buttoning & unbuttoning a shirt are typical behaviors.

Psychomotor retardation is marked by slowing of speech, increased

pauses before answering, soft or monotonous speech, poverty of

speech & muteness. Slowing of body movements also occurs.

Patients may feel tired all the time. The smallest task may seem

impossible.

Activities of daily living suffer also. Poor personal hygiene may be

caused by the lack of energy (depressed adults lie in bed & become

incontinent or constipated because of the inability to muster the

energy & motivation to walk to the bathroom.

Change in eating behaviors results in either a loss or gain of weight.

Sleeping behaviors also change. Depressed persons may often deny

being depressed, but are brought to the attention of the psychiatric

community by the complaint of always being tired, or taking too

many naps, daytime sleepiness, etc. Many patients want to lie down

but do not sleep.)

Altered social interactions –Patients are distracted easily & are not

interested in other people, or other ideas or problems. The self-absorbing

nature of depression leaves depressed persons with little to offer to others.

Conversations are difficult to maintain & only with great effort can

depressed persons sustain a facial expression of interest & concern.

Depressed persons are also withdrawn; they may withdraw form family &

friends & seek social isolation. Saddened expression & a drooping posture

serve as a social barrier.

Subjective:

Alterations of affect – symptoms primarily associated with depression

which dominate the internal world of depressed persons. (anger, anxiety,

bitterness, dejection, denial of feelings, despondency, guilt, helplessness,

hopelessness, uselessness, loneliness, low-self esteem, sadness, & a sense of

worthlessness)

Alterations of cognition (ambivalence & indecision, inability to concentrate,

confusion, loss of interests & motivation, pessimism, self-blame, self-

depreciation, self-destructive thoughts, thoughts of death & dying &

uncertainty)

Alteration of physical nature – these subjective symptoms come to the

attention of the nurse because of the numerous complaints of depressed

patients. Some people become so preoccupied with their bodies that every

twinge, every body change is greeted with great alarm & dread. (abdominal

pain, anorexia, chest pain, constipation, dizziness, fatigue, headache,

indigestion, insomnia, menstrual changes, nausea & vomiting, sexual

dysfunction)

Alteration of perception – Typically delusions (delusion of persecution because of a

moral mistake, somatic & nihilistic delusions, are common in depressed patients)

& hallucinations (tend to be less elaborate than those of schizophrenics & tend to

focus on personal faults)

D. Psychodynamic Treatments for Depression

4. Discuss at least 5

Nursing Interventions

(with rationale) for

Depressed &

Withdrawn clients

1. Supportive Psychotherapy – this approach attempts to guide patients in

reference to their environment.

2. Psychoanalysis – this approach conceptualizes depression as arising from

early life, deprivations of love & affection, or from conflicts resulting from

an overly severe conscience

3. Interpersonal theory – attempt to explore losses related to interpersonal

relationships & deficits in social skills in order to understand the

relationship of the losses to the depression

4. Cognitive Behavioral therapy – the goal of the therapy is to reverse these

beliefs & attitudes

5. Marital & Family Therapy – life at home is considered a major contributor

to depression. Therapy goals include resolving family conflicts &

establishing the family as a base of support

E. Nursing Interventions

Depressed Patients:

Provide a safe environment for the client.

Rationale: Physical safety of the client is a priority. Many common items may be

used in a self-destructive manner.

Continually assess the client’s potential for suicide. Remain aware

of this suicide potential at all times.

Rationale: Depressed clients may have a potential for suicide that may or may not

be expressed & that may change in time.

Reorient client to person, place & time as indicated (ex. Call the

client by name, tell the client your name, tell the client where she is)

Rationale: Repeated presentation to reality is concrete reinforcement.

When approaching the client, use moderate, level tone of voice.

20 min.

Group Discussion

Avoid being overly cheerful.

Rationale: Being overly cheerful may indicate to the client that being cheerful is the

goal & that other feelings are not acceptable.

Avoid asking the client many questions, especially questions that

require only brief answers.

Rationale: Asking questions & requiring only brief answers may discourage the

client from expressing feelings.

Accept patients where they are & focus on their strengths

Rationale: Depressed persons have low self-esteem & this is the best approach to

recapturing some sense of value

Reinforce decision-making by patients.

Rationale: Depressed patients struggle to make even simple decisions. Decisions

may be symbolic & represent moving in a wrong direction. By reinforcing patients’

efforts to make simple decisions, the nurse helps patients move toward health.

Never reinforce hallucinations or delusions

Rationale: Confronting these psychotic symptoms tends to reinforce them. The best

approach is for the nurse to state his or her view of reality & to begin discussing

real people & events.

Allow (& encourage) the client to cry. Stay with & support the

client if he or she desires. Provide privacy if the client desires & if it is safe

to do so.

Rationale: Crying is a healthy way of expressing feelings of sadness, hopelessness,

& despair. The client may not feel comfortable crying & may need encouragement

or privacy.

Respond to anger therapeutically.

Rationale: Depressed persons are typically angry. By understanding that anger, is a

symptom of depression, the nurse can focus on the issue at hand & help patients to

move toward a more acceptable style of interaction.

It is not therapeutic to badger patients into making a decision, but it

is therapeutic to provide decision-making opportunities as patients

are able to comply.

Rationale: Some patients cannot make a decision. Initially. The nurse may need to

make decisions for patients (“it is time for your bath”). When possible, the nurse

helps to guide patients to appropriate problem-solving techniques; that is,

identifying options, the advantages & disadvantages of each option, the potential

consequences of each decision.

Involve patients in activities in which they can experience success

Rationale: People feel good about themselves in several ways. One way to develop

self-worth is through accomplishment.

It may be necessary to teach the client effective social skills such as

eye contact, attentive listening, & topics appropriate for initial social

conversation (ex. The weather, current events, local news)

Rationale: Even if the client knows these skills, practicing them is important – first

with the nurse & then with others. Practicing with the nurse is less threatening.

Help the client practice giving others compliments.

Rationale: This requires the client to identify something positive rather than

negative in others. Giving compliments also promotes receiving compliments,

which further enhances positive feelings.

Giving factual feedback rather than general praise.

Rationale: Reinforces attempts to interact with others & gives specific positive

information about improved behaviors.

Manage medications.

Rationale: The increase activity & improved mood that antidepressants produce can

provide the energy for suicidal patients to carry out the act. Thus, the nurse must

assess suicide risk even when clients are receiving these drugs. It is also important

to ensure that clients ingest the medication & are not saving it in attempt to commit

suicide.

Withdrawn Patients:

Keep contracts with withdrawn patients brief but frequent.

Rationale: Depressed patients often do not want anyone around or, at least, anyone

to talk to them. Unfortunately, their wishes are not a good indicator of what should

be done.

Spend time with withdrawn patients.

Rationale: Withdrawn patients are aware of their surroundings. By spending time

(frequent but brief contact) with these patients, the nurse communicates patients’

worth &, consequently, may be available during a time when patients feel

comfortable with initiating dialogue.

To spend time with patients is constructive; allowing patients to

isolate themselves is not.

Rationale: Patients may need to increase physical activity before they are able to

verbalize issues.

Locking a patient’s room during the day may be required to keep the

withdrawn or isolative patient from disappearing for hours at a time.

Rationale: Many patients are insistent about going to their rooms to lie down. They

may stay there all day if the nurse does not intervene. Sitting in silence during an

activity is better than ruminating in isolation.

5. Discuss briefly the

factors in the

assessment of the Self-

destructive patient

V. Suicide

Suicide is a complex phenomenon influenced by religious, cultural, &

psychological factors. Men are far more prone to it than women. The psychiatric

nurse continually must assess for suicide potential among all patients, but

especially among schizophrenic, depressed & alcoholic patients. Hendin (1986)

points out that suicide is most often the result of depression, diagnosed or not.

Suicidal patients view & utilize death differently from other people. There is a

tendency for suicidal patients to use their own death to control others & to maintain

control over their own lives.

A. Risk Factors

Hopelessness

General medical illness

Family History of Substance abuse

Depression

Substance abuse

Male gender

Caucasian race

Psychotic symptoms

Living alone

Prior suicide attempts

AIDS

B. Factors in the Assessment of the Self-Destructive Patient:

Assessing Circumstances of an Attempt:

Precipitating humiliating life event

Preparatory actions: acquiring a method, putting affairs in order, suicide

talk, giving away prized possessions, suicide noted

Use of violent method or more lethal drugs/poisons

15 min.

Socialized

Discussion

Understanding of lethality of chosen method

Precautions taken against discovery

Presenting Symptoms:

Hopelessness

Self-approach, feelings of failure & unworthiness

Depressed mood

Agitation & restlessness

Persistent insomnia

Weight loss

Slowed speech, fatigue, social withdrawal

Suicidal thoughts & plans

Psychiatric Illness:

Previous suicide attempt

Mood disorders

Alcoholism or other substance abuse

Conduct disorders & depression in adolescents

Early dementia & confusional states in the elderly

Combinations of the above

Psychosocial history:

Recently separated, divorced or bereaved

Lives alone

Unemployed, recent job change or loss

Multiple life stresses (move, early loss, break-up of important

relationships, school problems, threat of disciplinary crisis)

Chronic medical illness

Excessive drinking or substance abuse

Personality factors:

Impulsivity, aggressivity, hostility

6. Briefly discuss the

risky behaviors of

suicidal patients.

Cognitive rigidity & negativity

Hopelessness

Low self-esteem

Borderline or anti-social personality disorder

Family History:

Family History of Suicidal behavior

Family history of mood disorder, alcoholism or both

C. Format for evaluating Suicidal Lethality

Plan – The more developed the plan, the greater the risk for suicide.

Persons who have developed a suicidal plan generally are more

serious about suicide & present a greater risk.

Method – Some methods of attempting suicide are more lethal than

others. Accessibility of the means to commit suicide is also

important.

Rescue – the person who deliberately attempts to deceive would-be

rescuers has a high lethality potential.

-In summary, the more detailed the plan, the more lethal & accessible the method

& the more effort that is exerted to block rescue, the greater the likehood of the

suicidal effort being successful.

D. Warnings of Suicide Intent & Risky Behaviors

- Most people with suicidal ideation send either direct or indirect signals to

others about their intent to harm themselves. The nurse never ignores any

30 min.

Group Discussion

7. Enumerate at least 5

Nursing

Responsibilities (with

rationale) for Suicidal

patients

hint of suicidal ideation regardless of how trivial or subtle it seems & the

client’s intent or emotional status. Often, people contemplating suicide have

ambivalent & conflicting feelings about their desire to die; they frequently

reach out to others for help. Asking clients directly about thoughts of

suicide is important.

- A few people who commit suicide give no warning signs. Some artfully

hide their distress & suicide plans. Others act impulsively by taking

advantage of a situation to carry out the desire to die. Some suicidal people

in treatment describe placing themselves in risky or dangerous situations

such as speeding in a blinding rainstorm or when intoxicated. This “Russian

roulette” approach carries a high risk of harm o clients & innocent

bystanders alike. It allows clients to feel brave by repeatedly confronting

death & surviving.

E. Nursing Interventions:

Provide a safe environment

Rationale: For suicidal patients, staff members remove any item they can use to

commit suicide, such as sharp objects, shoelaces, belts, lighters, matches, pencils,

pens, & even clothing with drawstrings.

Evaluate patients for suicide risk.

Rationale: Risk is based on plan, method & rescue prevention. By knowing the

risk, the nurse can establish a reasonable plan of care.

Suspect suicidal ideation in most depressed patients.

Rationale: Suspecting suicidal ideation prevents the nurse from overlooking a

potentially suicidal patient.

Inquire directly about frequency & content of suicidal ideation.

Rationale: the nurse will not provoke suicide by asking patients about it. In fact, the

nurse will convey concern, the worth of the patient, & a sense of understanding.

Furthermore, the nurse needs this information to plan care.

Ask patients about the advantages & disadvantages of suicide.

Rationale: This information enables the nurse to understand how patients see their

situations.

Evaluate patients’ access to a means of suicide.

Rationale: If the patient has a means of suicide, the nurse should arrange to have

that means blocked. For some patients, if the method of choice is blocked, they will

not use another method.

Develop a formal “no suicide” contract with patients.

Rationale: Many patients will honor the contract; hence, the nurse has one more

tool to prevent patients from self-injury. However, this contract is not a guarantee

of safety. At no time should the nurse assume that a client is safe just because a

contract is in place.

Advice patients to discontinue drugs &/or alcohol.

Rationale: Drugs & alcohol significantly increase the risk of suicidal behavior.

Support patients’ reason to live.

Rationale: As the nurse is able to align with the healthy part of each patient’s

personality, the nurse gains a therapeutic ally.

Create a support system list

Rationale: the nurse makes a list of specific names & agencies that the client can

call for support; he or she obtains client consent to avoid breach of confidentiality.

Face to face – in working face to face with suicidal patents, several general

guidelines are useful to the nurse:

References:

Johnson, B.S. (2000). Adaptation and growth psychiatric-mental health nursing. 3rd

ed. J.B. Lippincott: Philadelphia

Keltner, N.L., Schwecke, L.H., & Bostrom, C.E. (2007). Psychiatric nursing. 5th

ed. Mosby: St. Louis

Stuart, G.W. Laraia, M.T. (2001). Principles and practice of psychiatric nursing. 7th

ed. Mosby: St. Louis

Videbeck, S.L. (2006). Psychiatric mental health nursing. 3rd

ed. Lippincott: William & Wilkins, Philadelphia

Ask patients if they plan to hurt themselves. It is important to for the nurse

to understand the ff:

- Talking to patients about their suicidal intentions will not drive them to

suicide. Asking patients directly provides useful information & often

provides patients with a sense of relief.

- The nurse must take all suicidal threats seriously.

If the patient is considering suicide, the nurse should ask about the plan

(when & where), method, & how the patient intends to accomplish the

suicide.

Ask about previous suicide attempts (when & how)

Evaluate patients for depression, recent loss or threat of loss, self-

destructive hallucinations, & alcohol or drug-use, all of which place

persons at higher risk for suicide.

Once patients are hospitalized, most units protect them by using one of the

2 levels of suicide prevention:

a. Level 1 is used for patients who are not considered to be at immediate risk

for suicide.

b. Level 2 is used for patients who present an immediate & serious threat of

suicidal behavior.

VI. Open Forum

15 min.